Eligibility Specialist 2, Claims

Jobtailor; Deutschland; Remote; EUR 42.000 - 62.000; Vollzeit

Zusammenfassung

Jobtailor is seeking a detail-oriented Eligibility Reviewer to assess Long-Term Care policy benefit eligibility according to federal, state, and company guidelines.

You will determine approvals or denials, request medical records, update systems, and maintain documentation while coordinating with medical directors and clients on complex cases.

Strong knowledge of HIPAA, insurance regulations, and claims software is required for success in this full-time role.

Qualifikationen

• Maintain current knowledge of federal, state, and insurance regulations and requirements
• Maintain working knowledge of company claims and administrative software systems and Microsoft applications
• Maintain working knowledge of all company and services pertaining to the business segment
• Maintain knowledge of applicable company policies and procedures
• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information
• Maintain client and company quality and production standards

Aufgaben

• Review Long-Term Care policy benefit eligibility according to policy, company, state, and federal guidelines
• Determine eligibility approval or denial and applicable benefits and riders
• Interpret policy provisions to determine claim benefits
• Request claimant assessments and follow up for medical records, forms, statements, certificates, and other required information
• Update systems and documents throughout the eligibility process
• Review applicable reports and documents related to eligibility determination
• Send timely correspondence to claimants about benefit eligibility determinations
• Respond to internal and external stakeholder correspondence regarding benefits, eligibility, claim payments, denials, and explanations of benefits
• Document eligibility rationale and determination basis in appropriate systems
• Collaborate with management, medical directors, and clients on complex eligibility cases
• Interact with other business units to gather and analyze data for claim adjudication and claim-file documentation
• Perform other assigned duties

Kenntnisse

Eligibility Determination

Claims Processing

Regulatory Compliance

Stakeholder Communication

Documentation Management

Tools

Claims Software Systems

Microsoft Applications

Jobbeschreibung

• Review Long-Term Care policy benefit eligibility according to policy, company, state, and federal guidelines
• Determine eligibility approval or denial and applicable benefits and riders
• Interpret policy provisions to determine claim benefits
• Request claimant assessments and follow up for medical records, forms, statements, certificates, and other required information
• Update systems and documents throughout the eligibility process
• Review applicable reports and documents related to eligibility determination
• Send timely correspondence to claimants about benefit eligibility determinations
• Respond to internal and external stakeholder correspondence regarding benefits, eligibility, claim payments, denials, and explanations of benefits
• Document eligibility rationale and determination basis in appropriate systems
• Collaborate with management, medical directors, and clients on complex eligibility cases
• Interact with other business units to gather and analyze data for claim adjudication and claim-file documentation
• Perform other assigned duties

Requirements

• Maintain current knowledge of federal, state, and insurance regulations and requirements
• Maintain working knowledge of company claims and administrative software systems and Microsoft applications
• Maintain working knowledge of all company and services pertaining to the business segment
• Maintain knowledge of applicable company policies and procedures
• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information
• Maintain client and company quality and production standards

Core Competencies

Demonstrates expertise in Long-Term Care policy eligibility determination, ensuring compliance with federal, state, and insurance regulations. Proficient in managing claim processes, stakeholder communication, and documentation while maintaining high-quality standards.

Highest-signal resume keywords

• Eligibility Determination
• Claims Processing
• Regulatory Compliance
• Stakeholder Communication
• Documentation Management

Hard Skills

• Policy Interpretation
• Benefit Analysis
• Data Analysis
• Claims Adjudication
• Medical Record Review

Soft Skills

• Collaboration
• Attention to Detail
• Problem-Solving
• Time Management

Industry Keywords

• Long-Term Care
• HIPAA Compliance
• Insurance Regulations
• Eligibility Guidelines

Tools & Technologies

• Claims Software Systems
• Microsoft Applications